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Presumed consent (PC) legislation has been touted as a potential solution to the disparity between supply and demand for deceased donor organs. This study examines the legislation in European countries with and without presumed consent legislation and reports on interviews with senior transplant physicians in these countries. The authors conclude that there are multiple country-specific, non-consent factors that better explain the differences in donation rates in some countries , and that PC legislation alone is unlikely to significantly increase donation rates.